Microsoft word - neshr adoption application

Adoption Form Name: ____________________________________________________________________ Birthdate (MM/DD/YYYY): __________________ Street Address: ____________________________________________________________City: _____________ State:_______________ Zip Code:______________________ At this time we can only accept applications from Delaware, Maryland, New Jersey, New York, and Pennsylvania. If you live in another state, you must contact the rescue directly to determine if we can process your application.E-mail: (1) ______________________________ (2) _______________________________ By entering a valid e-mail address, you will receive a confirmation that your application was submitted via e-mail. If you do not get a confirmation, please contact the rescue at adoption@neshr.org

Phone: (Home) __________________ (Cell) __________________ You MUST provide two references of people that are NOT family. You MUST also provide the following for both: NAME, PHONE, E-MAIL and you’re relationship with this person.

Reference 1: ____________________________________________________________________ Reference 2: ____________________________________________________________________ Siberian Husky ExperiencePlease check which applies the best for you: ___Owned pure Siberian(s) for less than 5 years
___Owned pure Siberian(s) for 5-10 years
___Owned a Husky mix currently or in the past
___Owned pure Siberian(s) for more than 10 years
Other Breed Experience: ____________________________________________________________________ What other breeds of dogs do you have experience with? Tell us about the breeds you have owned in the past.

Current Dogs: ____________________________________________________________________ Pets Given Up: ____________________________________________________________________ If you have ever given up a dog or other pet, please explain the circumstances here. If you have not given up a pet, please state that here. Own / Rent / Other: Please check which applies the best for youPet Approval: Please check which applies the best for you:___My lease states I can own dogs of any size ___My landlord has given permission to own a dog ___I need to obtain permission from my landlord ___I have approval from my family ___I own my home and have no township restrictions to dog ownership ___I own my own home but am subject to certain community restrictions ___My lease states I can own dogs of any size Landlord Info: ____________________________________________________________________ If you rent, provide the name and phone number of your landlord or rental agency.

Home Type: Please check which applies the best for you:___Single Family Years Residing: Please check which applies the best for you: ___Less than 1 year

Yard Description: Please check which applies the best for you: ___ Yard is NOT Fenced
___ Yard is NOT fenced, but plan to install
___ Yard is Fenced AND has kennel or pen
Veterinarian Info

Name: ___________________________________________________________________ Please provide us with a name of a vet you currently use or have used in the past. If you are new to pet ownership, please provide the name of the vet you intend to use.

Home Check Objection: ___________________________________________________________________ Do you object to a home check? If so, please explain why

Alternate Dog: Please check which applies the best for you
___I am interested in other dogs___I will Consider others if it is a better match for meBreed Research: Please check which applies the best for you
___Yes, I have read all the info on this site___I have not read all the information but am knowledgeable of the breed ___I plan on reading more information on the breedAdoption fee acknowledgement___ (please check) Please confirm you are aware that our adoption fees are: Puppies to 6 months are 450 (If not already altered they are 300 plus a 150 spay/neuter deposit). Dogs 6 months to 8 years of age are 275. Dogs 8 to 10 years are 150. Senior dogs over 10 years of age are a donation that you feel is appropriate. Second dogs adopted from Northern Exposure Siberian Husky Rescue earn a 50 dollar discount.

Although your procedure was performed in an office-based setting, it is still a serious surgical procedure. Postoperative care is very important. Careful attention to the following instructions will help prevent complications, minimize discomfort, and promote proper healing. 1. Drink plenty of fluids following your surgery for 1-2 days. 2. Eat light—salads, soups, breads to avoid nause

8559.Prescription_chart 29/11/04 1:42 pm Page 1 Prescription Chart For Anticoagulant Prescribing Please complete this chart and update as necessary. Patient Details (PAS Sticker) This chart should always remain on the ward. Discharge Instructions • On the day of discharge send this chart to the Weight (kg) anticoagulation appointment and a yellow warfarin book, which will be issued